When 29,000 mothers-to-be were wheeled into delivery rooms at Air Force hospitals in 1982, they expected the pain of labor. But for some, the suffering lasted much longer. They went home recovering from severe cuts and tears that occurred at a rate twice the national average.
At one Army hospital in 1984, a physician wrote in his weekend hospital record that he had distributed 243 doses of one drug to patients. No one was required to review drug usage at the hospital. So no one suspected that the doctor was feeding his own habit.
Two dozen military doctors figured they had found a smart way to beat the recession in 1982. Scheduled for work at military bases, they instead saw patients on government time at a civilian hospital miles away. They took paychecks from both.
Such stories, once told in whispers, are at the heart of unprecedented reports that, taken together, show that U.S. military hospitals form a health care network that ignores some controls and does not have others.
The reports say there is no way of knowing the scope of the problem at the hospitals, which care for 10.2 million active service personnel, retirees and dependents.
Audits of Navy, Army and Air Force hospitals reveal, among other deficiencies, that hundreds of their 13,704 doctors were approved for practice with only cursory reviews, others had unrestrained access to military pharmacies and some worked private jobs on military time at sites more than 200 miles from their military bases.
The audits were prompted by an inquiry from Defense Secretary Caspar W. Weinberger in 1982 after the government lost a $2.1 million negligence suit, then the military's single largest malpractice loss.
Since then, the cost of malpractice settlements against the federal government for military health care has increased substantially. Recently compiled Defense Department figures show that medical malpractice claims cost taxpayers about 41 percent more in 1984 than two years earlier. The government, the only entity that can be sued in a military case, paid $29 million in 1982 and $41 million in 1984.
The Defense Department is reviewing the audits and is instituting reforms that include tougher reviews of military physicians' credentials, restrictions on moonlighting and a proposal for federal licensing of doctors either in the military or hired by the military.
Weinberger, who has met with health specialists in the Defense Department to discuss the audits, said last week in a prepared statement that he "emphatically expects the quality of military health care to be of the highest standards and . . . we expect rapid and decisive response" to medical errors.
Five of the Defense Department audits were conducted from June 1983 through July 1984 by the Navy, Army and Air Force audit services and the inspector general, a watchdog for military affairs. All those audits show that divergent and weak controls over physicians exist in each branch of the service. No doctors are identified and few hospitals named.
Each audit checked the enforcement of Defense Department's quality assurance policies, designed to safeguard patient care. One of the first mandates of the program begun in 1982 was that each service develop procedures for reviewing a doctor's credentials before he or she could be allowed to practice at a military hospital.
A review of enforcement at individual hospitals found discrepancies. The audits show:
* Army doctors were authorized to practice without proper verification of their training or experience. Of 366 Army doctors' files reviewed, 362 or 98.9 percent did not provide information on training or experience.
* None of the Air Force hospitals surveyed was complying with Air Force credentials requirements.
* Navy recruiters did not obtain or verify data for first-time military doctors, and the files of 25 new doctors had no documentation. Two civilian doctors who had never been granted hospital privileges at a military hospital were working at one hospital.
* The inspector general's office found that 213 out of 251 military doctors surveyed -- 85 percent -- were cleared for practice before credential files from previous hospitals had arrived. One hospital review committee took 40 minutes to recommend 86 professionals.
Those surveys were conducted as a criminal case against a civilian doctor approved for duty by the Army wound its way through U.S. District Court in Camden, N.J.
Abraham V.K. Asante had been approved in June 1983 as a civilian anesthesiologist at Walson Army Hospital at Fort Dix, N.J. On Aug. 25, 1983, he was the anesthesiologist for an operation in which retired Navy Chief Petty Officer Joseph Branda, 46, suffered irreversible brain damage.
A check of Asante's records on Aug. 30 by hospital officials showed that he did not hold a Connecticut medical license, as he had stated in his application. A further check showed that Asante, who said he was trained at the University of Prague in Czechoslovakia, had no license at all, Army public information officers said.
Asante was convicted of aggravated assault, unlawfully dispensing narcotics and making false statements to the government while applying for employment. He was sentenced to 12 years in prison, according to the U.S. attorney's office.
Branda remains in a coma.
Last September, Branda's wife filed suit in U.S. District Court in Trenton, N.J., against the government, asking for $11 million in damages. Under a 1950 Supreme Court ruling known as the Feres Doctrine, active service personnel are forbidden to sue the government. But retirees can sue. The federal government -- not the doctor -- is liable in these cases.
In the initial surveys, each armed forces branch conducted its review and the inspector general's office submitted two separate studies. Six of the 36 hospitals operated by the Navy worldwide, including those in Bethesda and in Portsmouth, Va., were audited. Five of the 82 hospitals operated by the Air Force, which still is compiling some of its findings, were audited. Nine of the 50 hospitals operated by the Army came under review.
Ten Army, Navy and Air Force hospitals -- including the Naval Hospital in Bethesda -- were audited by the inspector general to assess moonlighting and clinical procedures. Another audit by the inspector general's office reviewed six hospitals -- two in each service -- to assess health care procedures.
Further studies are in the works. Later this month, the inspector general will compile an audit of 17 of the military's 168 hospitals, based on the initial audits and its own research.
The General Accounting Office, reacting to separate requests from Sens. James R. Sasser (D-Tenn.) and Claiborne Pell (D-R.I.), this month began to study health care indicators, such as lengths of stays in military hospitals, and how military hospitals handle incidents that lead to malpractice claims. And Health Data Institute, a private firm in Massachusetts, has recently finished a project for the Air Force to assess its health care standards.
According to a Dec. 3, 1984, internal memorandum obtained from Defense Department files, Health Data Institute reviewed Air Force data for 1982. There were 243,000 admissions to Air Force hospitals that year, and data from those admissions show "patterns of probable poor performance across several measures within certain military treatment facilities," according to the memo.
Childbirth, which accounted for 12 percent of admissions, was cited for high rates of complications during surgery. The occurrence of severe tears and cuts during delivery -- 40 to 49 per 1,000 women -- was twice the national rate of 20 to 22 per 1,000, the memo shows. Convulsions and comas, a risk "considered to be nonexistent in the 1980s except in low socioeconomic populations with poor prenatal care," also occurred at a rate higher than the national average, the Health Data memo says.
Dr. William Mayer, the assistant secretary of defense for health affairs, would not discuss any of the audits, which he said are under internal review, but he recently outlined policy changes designed to tighten control over medical personnel.
The first change, which Mayer ordered Jan. 26, requires that each service's hospitals review doctors' files twice a year. Peer groups will make the reviews, and the Defense Department will specify what documents must be in those files, Mayer said.
Other measures, to be considered in the next few months, include: outlining procedures to follow when checking reports of poor care; restricting the hours a doctor can moonlight and the distance he or she can travel to a second job; establishing a federal medical licensure test, and reviewing emergency room procedures and personnel qualifications.
Mayer said last week the policies set by his office will be reviewed for enforcement by individual hospitals, inspectors general in each service branch and the inspector general of the Department of Defense.
"Military services are based on the premise that orders must be followed," Mayer said. "A policy order is a direct order from the secretary of defense, and it is expected orders will be obeyed."
Scrutiny of the military's medical system began a few months after the federal government in January 1982 lost a $2.1 million malpractice suit, stemming from an operation by an Air Force surgeon.
Takuye Green of Wisconsin suffered brain damage and was blinded and paralyzed during a bypass operation on May 2, 1978, at Milwaukee Lutheran Hospital. The first assistant surgeon in the case was Dr. William Stanford, chief cardiologist and chief of surgery at Wilford Hall Medical Center, Lackland Air Force Base, in San Antonio.
Stanford was on leave while he conducted the operation at the private Milwaukee hospital. The government, as Stanford's employer, was named as a defendant in the suit.
Stanford was found negligent in U.S. District Court along with two other members of the surgical team for connecting a heart-lung machine backwards and depriving Green's brain of oxygen for 20 minutes. Stanford retired from the Air Force in 1980 and later went into private practice.
An internal report to the secretary of defense, dated Dec. 30, 1982, states that there had been "serious concerns" voiced by the professional staff at Wilford Hall in San Antonio from 1975 through 1977 about Stanford's ability as a heart surgeon. On June 1, 1977, the hospital commander limited the kinds of surgery that Stanford was allowed to perform. In fall 1977, Stanford went to Milwaukee to obtain additional training to "sharpen" his surgical skills, the report says.
The Green operation occurred during that training, the report says.
Five months after the Green decision, the Department of Defense ordered each branch of the service to begin quality assurance programs. Since that time, the department has issued seven health care standards.
Included in those standards are requirements for hospitals to report physicians to the state in which they are licensed if they leave the military while their hospital practices are formally questioned, maintain quarterly reports on malpractice claims, and collect quarterly reports of doctors' credentials.
One additional standard ordered in March 1983 was that military hospitals collect and report data on deaths to determine acceptable levels at military hospitals, according to the audit by the inspector general's office.
But in surveys conducted from May 1983 through September 1983 by that office, no such data had been analyzed for any doctor in any of the services. The same study shows many Department of Defense standards went unheeded -- including one that required hospital staff at outpatient clinics to refer to doctors patients with repeated complaints.
The method for approving and appointing doctors in military hospitals -- a method called credentialing -- was by far the most criticized procedure in three of the reports. In the inspector general's report, three of the six hospitals surveyed did not take "firm action" -- such as suspending the credentials -- in the cases of three unidentified doctors whose quality of care was questioned.
In another criticism, the report cited an Air Force physician who was suspended as a result of allegations of sexual improprieties with a patient. That man's credentials were reinstated one day before retirement.
The timing of that criticism hit close to home when, a week after some of the audits became public, the head of anesthesiology at Walter Reed Medical Center was reinstated. Dr. Robert L. Watson had not been allowed to practice there after he had been convicted of taking money illegally from drug companies. Immediately after his credentials were reinstated, Watson went on leave and submitted a request for retirement.
Watson, who now is serving five years' probation, was contacted at his home last week and defended the reinstatement of his privileges. His medical proficiency was never questioned in the investigation by the FBI and Army that led to the charges, he said.
"There was no question of my clinical competence," said Watson.
The inspector general's report refers to Army and Navy cases in which doctors under investigation "adversely affected" the careers of hospital workers who were witnesses against them.
According to a prosecutor's memo in U.S. District Court, Watson took steps to harass witnesses against him. He removed one witness as director of residency training and accused another of narcotics abuse. The latter witness was strip-searched for needle marks, the memo said.
Watson, who is still waiting a decision on his retirement, last week admitted that he took money from drug companies but denied that he tried to intimidate witnesses or that he ordered a strip search. Watson said he took actions to rid Walter Reed of "malcontents . . . who were trying to entrap me ."
One recommendation of the audit is that the Defense Department develop a policy that would allow anonymity for witnesses until a formal hearing is set or investigation begun.
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